Hadassah MEDICAL FOREFRONT Information and Updates for Doctors in the Community Autumn 2002 Editor: Prof. Shmuel ShapiraDear Colleagues,Hadassah, as a leading health organization, has a central aim of strengthening its linkswith the community. The patient arrives at the hospital from the community, and inmost cases will return home. Thus the proper chain of treatment demands continuousconsultation between doctors in the medical center and those in the community, adialogue with many faces: referral of patients, direct contact and detailed transfer ofinformation accumulated during assessment and treatment, feedback betweencommunity physicians and the hospital and vice versa.As part of this dialogue we have been working in recent months to improveHadassahs Web site, both graphically and technically and also regarding its content.At the same time, I as an Internet fan know that the printed word has much value ofits own. Even the highest-resolution computer screen will not replace the easyaccessibility of printed pages or even the good and fresh smell of the paper.Therefore, we saw the need to create this newsletter, which will supply informationon unique medical services at Hadassah to physicians in the community.Recently we have been working to preserve the balance between the need to copewith horrible terror attacks and to continue providing tertiary medical services,developing centers of excellence and building infrastructure. I believe we are meetingthese targets with honor and are not sacrificing the future for the difficult present weface.I hope that the coming year will be a better one for all of us, and that we will continueto strengthen the connection between community physicians who stand at the frontline of health services and Hadassah, which is at the forefront of medicine. Prof. Shmuel Shapira, Deputy director-general, Hadassah Medical Organization ***************************************
MAZE SURGERY –INNOVATIVE TREATMENT FOR ATRIALFIBRILLATIONBy Dr. Niv Ad, Cardiothoracic Surgery Department, Hadassah Ein KeremAcute and chronic atrial fibrillation is the most common arrhythmia in the adultpatient. Its prevalence in the Western world is about two percent of the generalpopulation and up to six percent of those over the age of 65. In recent years, we havewitnessed an increase in awareness of morbidity and mortality directly connected tothis condition. If in the past, we regarded the condition as reducing the patientsquality of life, today were aware of the fact that atrial fibrillation increases the risk ofembolism especially in the brain. In addition, it has a clear and direct connection to ahigher risk of death (Framingham Study).Data accumulated in recent years have brought about significant changes in thetreatment approach to this large group of patients. Those at high risk for embolismareinstructed to take Warfarin against clotting. This group of patients is defined aselderly over the age of 65, diabetics, hypertensives, patients after an embolism andpeople suffering from cardiac insufficiency. Giving Warfarin to such patients reducesby half the risk of an embolism, but it doesnt eliminate the threat completely.Take, for example, an elderly patient with high blood pressure, the risk of a strokewithout Warfarin is five percent per year and with Warfarin half of that. Not only that,but those who take the drug have a significantly higher risk of hemorrhage. Inaddition to anti-clotting treatment, there has been a major advance in medicationprotocols against arrhythmia that integrate control on the heart rate and the rhythm.Besides medications, "smart" pacemakers and atrial defibrillators have beenintroduced, but their effectiveness for treating the condition is still very low.Its interesting to point out that as early as the 1980s, Dr. James Cooks of St. Louis inthe US developed a technique called the Maze Procedure that was successful in over90% of cases in curing arrhythmia. The operation appeared prematurely as it was verycomplicated and thus had few advocates.At the end of the 1990s, the French cardiologist M. Haissaguerre of Bordeaux foundthat most stimuli that cause only acute atrial fibrillation alone come from pulmonaryveins in the left auricle. Based on these findings, a percutaneous treatment techniqueaimed at isolating the pulmonary veins in the left auricle was developed.There is no doubt that these two researchers brought about a revolution in availabletreatment methods benefiting patients with the condition who cannot be helped byother techniques. The main limitations of the percutaneous technique are low successrates (50%) and even lower in patients who have chronic fibrillation. In addition,there is quite a high incidence of narrowing of the pulmonary veins and greater risk ofstrokes, especially in patients with a history of embolism in the brain.
The main shortcoming of the Maze Procedure is the need for an open-heart operation,but at the same time the success rates in treating acute and chronic atrial fibrillation(up to 95%) are impressive. The old technique has been replaced by cryosurgery usingspecial catheters developed for this surgery. This makes it possible to perform less-invasive operations, without prolonged use of a heart-lung machine. Cryosurgerypreserves all the principles of the original Maze technique, and treats both auricles(unlike the percutaneous and other techniques). The freezing technique increases thechances for success in curing the two kinds of atrial fibrillation.Like any other technology, this one – despite its efficacy – is not suited to all patients.It is carried out in patients referred for open-heart surgery for another reason (such asvalve repair or bypass) and people who have had atrial fibrillation for more than sixmonths. One can also consider using the operation in patients after a stroke or thosewho are at very high risk. The Maze Procedure could also be considered in patientswhose quality of life has significantly declined due to arrhythmia or as a result of sideeffects from medications.A clinical and research infrastructure has been set up at Hadassah to treat the disese.Experience accumulated in the US as a result of close work with the developer of thetechnique, Dr. Cooks, has brought about very impressive results. By working closelywith several centers abroad and having ongoing contact with Dr. Cooks, we areleaders in the world today in performing the Maze Procedure with crysurgery and areinvolved in all new developments in the field at the clinical and research level.For more information:Dr. Niv AdCardiothoracic surgery department, Hadassah University Hospital at Ein KeremTel: 02-6777024, 6776960e-mail: firstname.lastname@example.org *********************************************
MYOMAS: NEW TREATMENT TECHNIQUES Dr. Asher Shushan, Gynecology and Obstetrics Department, Hadassah Ein KeremMyomas (intrauterine lesions) are a common problem that appears in about a quarterof fertile women. Myomas are benign growths in the uterine muscle that are liable tocause infertility repeated miscarriage, increased menstrual bleeding and pelvic pain.They thus significantly harm the quality of life of many women.Myomas and the suffering they cause are the main reason for hysterectomies in theWestern world. Scientific research has shown that myomas are influenced byhormones, steroids and estrogen and progesterone inhibitors used to shrink myomas.But these drugs, such as the analogs of GNRH (Gonadotropin Releasing HormoneAnalog), which reduce estrogen, have only a temporary effect and significant sideeffects as well.Thus, due to the lack of effective mediation, the most common treatment is surgical.The most "efficient" treatment for myomas is removal of the uterus, which ensure thatno more lesions with grow and that the symptoms such as increased menstrualbleeding or lower abdominal pain with be halted. But in recent years, more and morewomen have been interested in less invasive means as an alternative to hysterectomy.The advantage of minimally-invasive surgery or other interventions is that iteliminates the need to open the abdomen, and the hospitalization and recovery periodsare much shorter than laparotomy. The possibility of using minimally-invasivetechniques depend on the location of the myomas, their quantity and size, as well asthe womans age and her plans for future childbirth.We in the Hadassah gynecology and obstetrics department at Ein Kerem offer womeninterested in alternatives a variety of techniques:1. Hysteroscopic removal of myomas:This is suitable for submucosal lesions up to five centimeters in size. In most cases,these myomas cause increased menstrual bleeding and repeated miscarriages. Theoperation is carried out through the vagina using a resectoscope. Sometimes thewoman has to be given a GNRH analog injection to shrink the myoma and shorten thetime for the surgery. The operation usually requires a days hospitalization, allowingfull and speedy return to activity. It does not require a Cesarean section for the nextpregnancy. Recently we have shown that hysteroscopic operations are also suited topost-menopausal women in whom a benign growth is found in the uterus and thetechnique eliminates the need for a hysterectomy.2. Laparoscopic removal of myomas:This method is suitable for women who suffer from subserosa myomas that causepain or pressure in the pelvis (possibly pressure on the bladder). This techniqueseparates the myoma from the uterus using endoscopic tools; the lesion is them takenout of the abdominal cavity using a device that cuts the tissue into thin strips. Themuscle "bed" that remains is sewn up and the structure of the uterus is restored.Recuperation is much faster than after a laparotomy.
3. Catheterization and blockage of the uterine arteries to treat myomas:This technique involves catheterization of the ileum and imaging of the arteries thatsupply blood to the uterus and myomas. After the catheter is inserted, tiny particlesare injected to cause a blockage. This is carried out in the imaging department andinvolves hospitalization of a day or two for observation and relief of pain. So far,thousands of these procedures have been carried out around the world with a highsuccess rate (up to 90%). Because of the rare complication of harming blood supply tothe ovaries, we perform this technique only on women who dont want to have morechildren.4. Experimental treatment using high-powered ultrasound with MRI:We are participating in research being carried out in a number of centers abroad thatis examining the possibility of using focused and high-power ultrasound to heat themyomas to 70 degrees Celsius and cause it to waste away without harming the uterinemuscle. The ultrasound ray is controlled and aimed at the lesion using MRI. It takesthree hours in the MRI unit, after which the patient goes home.The various techniques for treating myomas make it possible for our department tocustomize a suitable treatment package for every woman and achieve the maximumresults.For more information:Dr. Asher ShushanDepartment of Gynecology and Obstetrics, Hadassah University Hospital atEin_Kerem02-6733334e-mail: email@example.com ****************************************
INVASIVE NEUROANGIOGRAPHY: A GOOD AND SAFE SOLUTION Prof. Moshe Gomori, and Dr Jose Cohen, Radiology Clinic, Hadassah Ein KeremImportant developments in neuroangiography are in two general trends. One is non-invasive diagnosis and the other in invasive neuroangiography. Arterial angiographyusing a CT or MRI is called CTA or MRA for arteries and CT or MRV for veins.These examinations make it possible to carry out high-quality non-invasive vasculardiagnoses. CTA is cheaper and faster but suffers from camouflage by bones nearblood vessels, especially at the base of the skull. In addition, it requires the use ofcontrast materials based on iodine and radiation. Thus CTA is not suitable for patientssuffering from renal insufficiency.A Duplex test is the first step towards assessing the constriction of the carotid artery.If its narrowed by more than half, conventional catheterization is needed to authorize,and if necessary to plan, the treatment.In addition, conventional catheterization makes it possible to assess inra-brainnarrowing, Willis’ Circle collateral flow and micro-hemodynamics of the brain(parenchymography). Until now, it was impossible to treat such intra-cranialconstrictions. Now, using invasive neuroangiography, we can open these constrictionswith small and delicate intra-cranial stents.Invasive neuro-radiology offers a number of innovative treatments, such as expandingconstrictions in the carotid artery, using a stent, while protecting the patient fromembolisms in the brain using a micro-filter without blocking the flow of blood to thebrain. This revolutionary technique has lower morbidity rates than the conventionalcarotid endarterectomy.Its worth noting that the level of neurological complications is lower in thistechnique, which is performed without anesthesia.In cases of acute cranial infarction, there is a possibility of dissolving clots andimproving the neurological situation by performing the intervention within four to sixhours of the event. If the cause of the Clot is constriction of the cranial arteries, thiscan be opened by using an inter-cranial stent.If experienced doctors such as those in Hadassah carry out this technique, the risk ofpermanent harm from diagnostic catheterization is only 0.1%. In addition to the newapproaches to stroke, our unit deals with aneurysms and vascular malformations in thebrain and spinal cord using invasive neuroangiography.Treating aneurysms this way has become the preferred method, with low morbidityand complication rates compared to conventional treatments. The treatment is withGugliemi detachable coils (GDC) tiny and delicate platinum coils that fill theaneurysm. For vascular malformations, we use glue that is injected into the center ofthe malformation using a special micro-catheter that is able to reach a centimeter fromthe cortical surface of the brain.An additional new field in neuro-invasive treatment, in cooperation with theneurosurgery and orthopedic departments, is vertebroplasty. This is a percutaneous
treatment for osteoporotic or pathological fractures of the vertebrae that dont respondto conservative treatment. In this technology, a transpedicular needle is inserted intothe body of the vertebra and through it a venograph is performed. Taking the resultsinto consideration and under x-ray, cement is injected into the venal-trabecular [???]spaceof the body of the vertebra. The support from the cement strengthens thevertebra and prevents the development of micro-fractures. As a result, the pain isreduced. This treatment is carried out without general anesthesia, and the patient canstart walking within hours.In summation, advanced technology, technical skill and much experience in theneuroradiology unit at Hadassah make possible the diagnosis and treatment approachto pathology in small blood vessels that were very difficult to reach in conservativetechniques.For more information:Prof. Moshe Gomori051-874183e-mail: firstname.lastname@example.orgDr. Jose Cohen051-874284e-mail: email@example.com ****************************************
TREATMENT FOR MORBID OBESITY USING THE LAPAROSCOPICTECHNIQUEDr. Beglaibter NahumA multidisciplinary team at Hadassah University Hospital on Mount Scopusspecializes in treating morbid obesity using minimally invasive surgery (laparoscopy)and supportive therapy. An accepted therapy worldwide today, which is alsoperformed at the Mount Scopus hospital, constricts the stomach by using a modifiablering. This technique is carried out with laparoscopic surgery – via a number of tinyincisions in the abdominal wall, a ring that hugs the upper part of the stomach andcreates a pocket with a volume of 15 square centimeters.Morbid obesity is, as its name suggests, a disease. Many studies have shown that themortality rate among people whose weight is 50 percent higher than it should be (byage and height) is double that of the general population. The death rate rises to asmuch as five times the usual rate, if the patient is diabetic. In younger age groups therisk is even greater: Mortality rates among the morbidly obese aged 25 to 34 is 12times higher and between 35 and 44 is six times higher.The US National Institutes of Science, in a consensus conference, recognizedhypertension, diabetes, high blood lipids, hypertrophic cardiomyopathy,hypoventilation and apnea syndromes, gall stones, osteoarthritis and psychosocialproblems as being caused by morbid obesity. Treatment for these diseases must alsoinclude attention to overweight. Large epidemiological studies such as the NursesHealth Study, the Framingham Study and others showed a clear connection betweenmorbid obesity and sickness and death from cardiovascular diseases and various typesof cancer.At present, surgical treatment for morbid obesity is the only one proven effective overthe long term. Surgery is indicated when the body mass index (weight in kilos dividedby height in meters squared) is over 40 or 35 in the presence comorbidity and thereare other disorders such as those mentioned above.One must remember that the operation is not indicated for cosmetic purposes, andthey do not remove fat tissue from parts of the body. With the advances in minimallyinvasive surgery, laparoscopic techniques have been developed to deal with morbidobesity.The most accepted laparoscopic technique today is constricting the stomach with amodifiable ring. The ring is attached to a tiny tube and an injection device placedunder the skin of the abdominal wall. This device can gradually inflate the ring andthus control the size of the passage between the packet and the rest of the stomach.This operation does not cause any harm to the digestive system, and no other pocketsor cuts are crated. This greatly reduces complications, as the operation is totallyreversible, and if there are problem in the future, the ring can easily be removed,causing the original situation to return. Even though this operation is not without anycomplications, its minimally invasive nature brings them to a minimum and thepatient usually recovers quickly. Patients are discharged from the hospital the nextday.
During the days and years after the surgery, patients undergo regular and carefulcheckups by the surgical team, dietitian and social worker.This operation, which is very common in Europe, Australia and South America,already received approval over a year ago from the US Food and DrugAdministration, and now it is being offered in a growing number of centers in the USas well.In Israel, the operation is included in the basket of health services (provided by thehealth funds) for the indications mentioned above. The hospital receives a specialdifferential rate for the procedure, and the insurer covers the purchase of buying thering and hospitalization.More than a tear ago, we started carrying out the operation in the Mount Scopussurgical department. For this, a multidisciplinary team with much experience wasestablished. It includes experts in laparoscopic surgery, a dietitian with experience intreating obesity, a social worker, radiologist and anesthesiologist who has workedwith such patients.For more information:The obesity clinic is open every Sunday between 10 a.m. and 12.30 p.m. on thesecond floor of the clinics building at the Mount Scopus Hospital. We will be happyto see your patients for providing information and counseling and to give them thebest care.Telephone: 02-5844111Fax: 02-5844584e-mail: firstname.lastname@example.org ********************************************
CLINIC FOR TREATING OBSTRUCTIVE SLEEP APNEA SYNDROMEAND SNORING Dr. Eitan Hochvald, Otolaryngology and Head and Neck Surgery DepartmentObstructive sleep apnea syndrome is a common disease involving about four percentof men and two percent of women. This phenomenon is caused by the blockageduring sleep of a number of regions in upper airways, including a "stuffed" nose, wideand long palate, long adenoids, enlarged tonsils, hypertrophic base of the tongue and asunken epiglottis.The condition causes a reduction in the amount of oxygen saturation of the blood,which results in changes in the blood vessels. It increases the risk of cardiovasculardisease, hypertension and stroke. In addition, people suffering from obstructive sleepapnea syndrome complain of headaches, difficulty in concentrating, tireness anddrowsiness during the day, including while driving.The diagnosis of the syndrome is made in a sleep laboratory, which documents theaverage number of times the patient stops breathing momentarily and the level ofoxygen saturation of the blood during sleep. Treatment is vital because it lowers therisk of the serious conditions mentioned above and improves the patients quality oflife.There are a number of treatments:1. CPAP – a mask suited to the nose introduces air under pressure during sleep. Thisis 100% effective, but a shortcoming is that many patients are unable to get used to it,so its only a temporary solution.2. Surgery – There are a number of types of surgery, depending on the location of theblockage: An operation to straighten the nasal septum if there is blockage in the nose;uvolo-palato-ringoplasty (UPPP) [CORECT SPELLING?] if the palate is wide orlong, the adenoids are long or the tonsils are enlarged; genioglossus advancement(advancing the small part of the chin and thereby advancing the base of the tongue, insituations in which this part is hypertrophic; hyoidopexy (advancing the hyoid bone ifthere is narrowing of the epiglottis and hypopharynx.These operations are relatively short with minimal complications, and they solve theproblem for about 80% of the patients. The operations great advantage, especially inrelatively young patients, is that is permanently solves their obstructive sleep anpneaproblems. Twenty percent of the patients who are not cured by the surgery canundergo a more major operation called maxillo-mandibular advancement, in whichthe upper and lower jaws are moved forward. The success rate is close to 100%, butthis is a major operation.Operations for the syndrome require teamwork of sleep physicians, ototlaryngologistsand oro-maxillar surgeons. The clinic at Hadassah University Hospital at Ein Keremis unique in that some of the operations mentioned here are carried out only there. The
clinic is also responsible for cooperation among various doctors who treat obstructivesleep apnea.All those who suffer from this condition also snore, but not all snorers haveobstructive sleep apnea syndrome. Snoring is a common problem among people overthe age of 40 – 60% of men and 20% of women in these ages snore.Snoring is an unpleasant social problem that can disrupt a couples life together. Sinceit is not a health problem and disturbs mostly the sleeping partner, the solution mustbe relatively easy for the patient.Snoring is caused by vibration of the muscles of the palate and pharynx. Overweightand blockage of the upper airways increase the negative pressure inside the oralcavity; this boosts the vibrations of the palate muscles and of the snoring.Weakened palate muscles, long adenoids and large tonsils also increase the noisefrom snoring. Operations performed in the 1980s included the UPPP, and in the1990s, lasers were used. In both cases, an incision is made in the soft palate and theadenoids are removed. These operations involved a lot of postoperative pain, so theylost their popularity. Not only that, but as time passed, the muscles of the palateweaken and snoring resumes, no other treatment could be offered.Four years ago, doctors in the US and Europe began offering a new snoring treatmentbased on radio waves called somnoplasty. This involves the transfer of heat energyusing a needle inserted into the palate muscles at three different points and using aspecial device to set the amount of heat and energy transferred to the muscles.The heating causes the protein in the muscles to be denatured, and within about sixweeks, a delicate scar is crated in the muscles. This scar causes them to become muchtougher, thus reducing the amount of vibration and significantly cutting the snoring.In most cases, the treatment has to be repeated after six weeks. It is an easy treatmentperformed in the clinic under local anesthetic and taking about 20 minutes.At Hadassah, we have performed somnoplasty on over 140 patients, almost withoutsignificant complications (except for two people with pain in the palate that persistedfor four or five day and two more people with edema in the adenoids, which passed afew hours later with steroid treatment).Seventy percent of patients said their snoring noise was cut by at least half (which isclinically considered a success), and another 20% said it was reduced but onlypartially. In about 10%, there was no improvement.The treatment is not effective in patients suffering also from obstructive sleep apnea,so these will have to undergo surgery or use CPAP.In summary, snoring is a very common social problem that can cause seriousproblems in a couples relationship. There is now a wide variety of good treatments.For more information:Dr. Eitan Hochvald [CORRECT SPELLING?], otolaryngology and head and necksurgery department, Hadassah Ein Kerem.Telephone: 051-874626 ******************************
CAPSULE ENDOSCOPY – AN INNOVATIVE TECHNIQUE TO EXAMINETHE DIGESTIVE SYSTEMProf. Yosef Zimmerman, Gastroenterology Department, Hadassah Ein-KeremThe small intestine was until recently very difficult to examine. Conventional imagingtests such as x-ray with barium or computerized tomography (CT) are not sensitiveenough to diagnose many pathologies in this part of the body. Most of the smallintestine is located beyond the range of the endocope and colonoscope.Endoscopic devices developed to examine the small intestine suffered fromlimitations in the range of their imaging, and thus their use is limited. But theinnovative Israeli development of the M2A (Given Imaging) capsule is abreakthrough in small intestine imaging. It is in actuality a tiny endoscope 26millimeters long and 11 millimeters wide. It looks like a capsule of antibiotics butsomewhat bigger. At one end is a source of white light that illuminates the inside ofthe intestine. It also has a lens, electronic circuits and a transmitter that sends radiosignals via an antenna and tiny batteries.The patient swallows the capsule, which makes its way through thegastroenterological system – pushed by peristalsis (the natural movement in thesystem). The signals are received by the capsule are transmitted via antenna to anexterior receiver that the patient carries on his body. The capsule broadcasts at a rateof two pictures per second. An hour after it is swallowed, it reaches the smallintestine, though which it passes in about four hours; then it goes through the largeintestine in another six hours. At the end of the "voyage," the disposable capsule isretrieved by elimination through the rectum, and the data recorded by the receiver aretransferred to a computer and processed with a special program.The batteries last eight hours – long enough to scan the whole small intestine. Theresults are very reliable, because the patient does not have to undergo sedation orinsertion of air to "inflate" the intestine as is done for a colonoscopy or endoscopy.This characteristic will make it possible to develop the capsule for measuring thephysiology of movement in the digestive system.The indication for using the capsule is a diagnosis of lesions in the small intestine.The typical patient suffers from chronic bleeding whose source has not been identifiedby conventional methods. Sometimes the capsule can even find lesions in thestomach, but at this stage of development, this is not the chosen method for examiningeither the stomach or the large intestine. The main contraindication for use of thecapsule is a blockage at any point in the digestive system, including adhesions aftersurgery that cause intestinal blockage. It is also not approved for use by patients withan implanted cardiac pacemaker or defibrillator.The patient must come to the lab when he is fasting. He should not take iron, sucralfat[SPELLING?], narcotic drugs, anti-spasmodic medications or laxatives before usingthe capsule. He should not wear tight clothing or belts during the test. After he isconnected to the exterior receiver and swallows the capsule in the lab, hes free toleave, but he must return four hours after he swallowed the capsule. He may even eat,but he would not overly exert himself or raise heavy objects.
Recently, we introduced use of the Given Imaging capsule in our clinic. For moreinformation:To undergo endoscopy with the capsule, call 02-6776849. The patient must have adetailed referral letter that explains the aim of the test and the patients clinical details,the medication he is taking and the results of previous tests he has done. At this stage,we are asking every patient to undergo a barium x-ray of the small intestine before heis permitted to swallow the capsule. We will be happy to accept suitable patients forthe test. *****************